As of August 23, the United States leads the world in monkeypox infections, with at least 15,433 cases in all states, according to the Centers for Disease Control and Prevention (CDC). Since the beginning of August, reported infections in America have more than doubled.
Globally, more than 42,900 cases have been recorded in 95 countries, the CDC reports. Since the first cases of this outbreak were detected in early May, the virus spread has been fast and unexpected, according the World Health Organization (WHO). The WHO calculated that almost 7,500 cases were reported in the week prior to August 17 — a 20 percent increase over the previous week, which was also 20 percent more than the week before.
After the United States, Spain has the largest outbreak, with 6,119 cases, followed by Brazil with 3,450, Germany with 3,295, and the United Kingdom with 3,081.
A week after the WHO deemed monkeypox to be a global health emergency on July 23, the United States followed suit, with the Xavier Becerra, secretary of the U.S. Department of Health and Human Services, declaring the virus a national crisis. The disease has the potential to cause serious illness, and according to the CDC a dozen deaths worldwide have been linked to the virus — although no one has yet died in the United States.
“We urge every American to take monkeypox seriously and to take responsibility to help us tackle this virus,” said Becerra at a press briefing.
While numbers have been rising, some indicators suggest that infections may be slowing in areas. In Canada, health officials said that cases are not increasing at the speed at which they were at the beginning of the outbreak. Politico reported that while cases are still rising in New York City, they appear to be slowing as of August 15. The United Kingdom recently announced that latest case figures show that the outbreak is beginning to slow with the daily average of cases at 29 from August 1 to 7 compared with 52 cases a day during the last week in June.
The U.S. Plan of Action
At a press briefing on August 18, Robert Fenton, the White House National Monkeypox Response Coordinator, said an additional 1.8 million doses of Jynneos monkeypox vaccine will be available, on top of the nearly one million doses of vaccines already delivered to states and cities.
To extend vaccine supplies, the U.S. Food and Drug Administration (FDA) recently granted emergency use authorization for the vaccine to be administered intradermally. Because intradermal administration requires a smaller dose, this change allows the number of available doses to increase by as much as fivefold while continuing to ensure the vaccine meets high standards for safety and quality.
Health officials hope this new approach will help meet the demand for vaccines, which has been exceeding supplies across the country, according to the Washington Post.
Federal authorities are also distributing more than 50,000 courses of TPOXX (tecovirimat), an antiviral treatment that is is FDA-approved for the treatment of human smallpox disease. Because monkeypox belongs to the same family of orthopox viruses as smallpox, the drug is thought to be helpful against monkeypox as well. The 50,000 courses of TPOXX is nearly five times the confirmed cases in the United States.
The federal government has also ratcheted up testing so the country can now administer 80,000 tests per week. CDC Director Rochelle Walensky, MD, MPH, encourages anyone who has a suspected rash that could be monkeypox to get tested. Individuals can usually schedule testing through a healthcare provider. Aegis Science, Labcorp, Mayo Clinic Laboratories, Quest Diagnostics, and Sonic Healthcare are among the labs testing for the virus.
“This is a unique outbreak, and that is spreading faster than previous outbreaks,” said Robert Fenton, the White House National Monkeypox Response Coordinator, at a press briefing. “We will leave no stone unturned in our efforts to combat this virus.”
Who Is Most at Risk
Based on the latest figures, the median age of those who are infected is 36, with a range of 18 to 76 years of age, and the vast majority of cases have been in people who identify as men who have sex with men (MSM).
Gay and bisexual men who have had sex with multiple partners are at particularly high risk of infection right now, according to the CDC. United Kingdom health services are advising individuals, particularly those who are gay, bisexual, or MSM, to be on the lookout for unusual rashes or lesions on any part of their body, especially their genitalia, and to contact a sexual health service if they have concerns. The symptom list in the United Kingdom was recently expanded to include a single lesion or lesions on the genitals, anus and surrounding area, lesions in the mouth, and symptoms of proctitis (anal or rectal pain or bleeding), especially if the individual has had a new sexual partner recently.
“It’s essential that all countries work closely with communities of men who have sex with men to design and deliver effective information and services, and to adopt measures that protect the health, human rights, and dignity of affected communities,” said Tedros Adhanom Ghebreyesus, PhD, director-general of the WHO. “Stigma and discrimination can be as dangerous as any virus.”
The WHO recognizes that the name of the disease itself could carry a negative connotation, and it is working on coming up with a new name to identify the virus.
Although the WHO has stressed that the general public is highly unlikely to get monkeypox, The Today Show reported on August 22 that at least 10 children in the United States have now contracted the illness. CNN reported that a minor in New York State was one of the most recent pediatric cases. Dr. Walensky told the Washington Post that children are most likely to get the virus if they come in close contact with the community who is most at risk. When an Illinois day-care worker tested positive for the disease earlier this month, health officials raced to screen children for the virus but no infections were detected, per CNN.
It’s unclear how many women have the disease, but several cases have been identified, including a female in Georgia, a woman in Virginia, and a pregnant woman.
A study published in The Lancet showed that pets can be vulnerable to the disease as well. Researchers recently found that a greyhound developed lesions and tested positive for monkeypox 12 days after its owners first experienced symptoms. The CDC now advises that people who are infected with monkeypox to avoid close contact with their pets.
The WHO warned that the public health risk could become high if the virus spreads to groups at higher risk of severe disease, such as young children and immunosuppressed persons.
“That scenario can be prevented,” said Dr. Ghebreyesus. “The WHO urges affected countries to make every effort to identify all cases and contacts to control this outbreak and prevent onward spread.
An Abnormal Outbreak
The WHO called the situation “unusual,” because this is the first time that monkeypox cases and clusters are being reported in widely different areas that have little or no association with West or Central Africa, where the disease primarily occurs.
“This is a very, very unusual infection in the United States and in the developed world,” said William Schaffner, MD, an infectious disease specialist and a professor of preventive medicine and health policy at the Vanderbilt University School of Medicine in Nashville, Tennessee. “Monkeypox virus lives in Africa, in a variety of different rodents, but occasionally gets into primates, such as monkeys, and hence the name, monkeypox.”
A study published in Nature Medicine found that the latest strain of the monkeypox virus has far more mutations than would be expected — including several that increase transmission.
Learn the Symptoms and Prevent Transmission
As monkeypox continues to spread, Walensky encourages all Americans to get educated about this disease, including how to prevent it, its symptoms, and how to get tested.
While rare, monkeypox has the potential to cause serious viral illness, notes the CDC. It typically begins with flu-like symptoms (fever, headaches, muscle ache, chills, exhaustion) along with swelling of the lymph nodes. The illness then progresses to an itchy rash on the face and body — often noticeable on the palms of the hands and soles of the feet. Some patients may develop a localized rash, often around the genitals, before any flu-like symptoms, and some have no flu-like symptoms at all.
“The classic presentation that we’ve seen in the past is that the rash first appears on the head or neck and then progresses in what’s called a centrifugal pattern. It leaves the center and it goes to hands, limbs, arms, legs, and soles of the feet,” said Rosamund Lewis, the technical lead for WHO’s monkeypox program in a YouTube webinar. Lesions then progress to the trunk and the genital area.
A lesion starts as a macule (a slight red patch on the skin). It then advances to a papule, which is a raised firm bump. And finally it becomes a vesicle, which is like a blister, with fluid inside.
Monkeypox has not previously been described as a sexually transmitted infection, but it can be passed on by direct contact during sex. Walensky noted that monkeypox cases may look like some sexually transmitted infections and could be mistaken for other diagnoses.
“What we know right now is that monkeypox spreads primarily through close skin-on-skin physical contact — by touching objects like sheets or towels that may have been used by somebody with monkeypox, and through close face-to-face interactions like kissing,” said Walensky in a press briefing.
The virus may also transmit between people through respiratory droplets in a close setting, such as the same household or a healthcare environment. Common household disinfectants can kill the virus.
Ghebreyesus recently stressed that person-to-person transmission is ongoing and is likely underestimated. “In Nigeria, the proportion of women affected is much higher than elsewhere, and it is critical to better understand how the disease is spreading there,” he said in a speech on June 23.
Walensky noted, however, that monkeypox is not thought to linger in the air and is not typically transmitted during short periods of shared airspace. “The virus is not thought to spread through interactions such as having a casual conversation, passing in the grocery store, or touching the same items, such as the doorknob,” she told reporters.
New research of concern from the CDC, however, found monkeypox virus genetic material on various items where in the home of two people infected with monkeypox. Those household items included cloth furniture, blankets, handles, switches, and chairs. Although scientists noted that they did not detect “viable virus,” more study is needed to investigate the potential for indirect transmission of monkeypox in household environments.
A recent study in the Annals of Internal Medicine warned that asymptomatic individuals could spread the disease — of 200 asymptomatic people who were screened, 13 (6.5 percent) tested positive for monkeypox.
Other research in Emerging Infectious Diseases has raised concerns as it detailed the case of an individual who contracted the virus after attending a crowded outdoor event but had no recent sexual activity.
How Effective Is the Vaccine?
The Jynneos vaccine is approved by the FDA for protection against smallpox and monkeypox in individuals 18 years and older who are determined to be at high risk of smallpox or monkeypox infection. Per the New York State Department of Health (PDF), the vaccine is administered in two doses at least four weeks apart, and full immunity is reached two weeks after the second dose.
The CDC says that “no data are available yet on the effectiveness of these vaccines in the current outbreak.” Still, studies in animals have been conclusive enough for the FDA to approve Jynneos to be licensed for prevention of monkeypox.
Past data from Africa suggests that the Jynneos and smallpox vaccine is at least 85 percent effective in preventing monkeypox, according to the CDC.
Dr. Schaffner adds that the smallpox vaccine has “a degree of effectiveness” against monkeypox, but large-scale studies have not been done. He expects the best way to control the spread will be by identifying those with the illness and isolating them.
Administering the smallpox vaccine on a wide scale would pose many challenges, he adds.
“Smallpox vaccine is not administered by a needle and syringe — it’s administered by a multiple puncture method,” said Schaffner. “It requires training in order to do that. We would have to train a whole bunch of people to administer this vaccine appropriately.”
It’s Possible to Get the Illness From Animals
Jennifer Horney, PhD, MPH, a professor of epidemiology and a core faculty member with the disaster research center at the University of Delaware in Newark, added that monkeypox is associated with unsafe domestication of wild animals and remains endemic in certain parts of the world. People can get monkeypox when they are bitten or scratched by an animal, prepare wild game, or have contact with an infected animal or possibly animal products. New CDC guidance includes avoiding close contact with sick animals.
“A large, 47-person outbreak of monkeypox impacted the United States in 2003,” said Dr. Horney. “That was traced back to contact with exotic mammals that were being kept as pets.”
Following that outbreak, the United States did not see any cases until last year, when Texas and Maryland each identified an infected person who had recently traveled to Nigeria, per the Massachusetts Department of Health.
People Who Should Be Especially Careful
The Massachusetts Department of Public Health says people may want to consult a physician about the possibility of monkeypox if they:
- Have an unexplained rash
- Have traveled in the past 30 days to a country with recent confirmed or suspected cases of monkeypox
- Have had contact with a person or people with confirmed or suspected monkeypox
- Are a man who has sexual contact with other men
For more about this virus, visit the CDC’s dedicated page.
